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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
f✓--------. - F..:.... / !.YS'5 .........................
Appliration for Disposal Works C onstrudion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�'�^ p Location-Address or Lot No.
1 014 r Z
......................-...... --�.-----:�'�=....-----•----•----......----•-------... ----- ......-��ff I ...... fi�!!:t�Y ......------•-
Owner _ _ Address
w 1'�:�':�-•---��eSS'�.'.c�olv--.....�'���.�//..�.._�.y--•--..._ .��...�..iQrS�j?o.�'��....z,� -•----•l�.Y, i�.P.....
a Installer� Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ..................................
------•--------------------------------------.......
----------
-------------------
W Design Flow............................................gallons per person per day. Total daily flow.._.............................__..........gallons.
WSeptic Tank—Liquid capacity............gallons Length—-____----__. Width................ Diameter--------------.. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
a . Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a Description of Soil---- :.................. - ---
x
V .....---•--•-•-•-••••-•••--••-•---••--•--•-•---........-•------••-------•----------------•----•--••-•--•-•---•-------------•------•--•-----•----------•---•---•---......................................
W -•----•-••••------ ---------- ----•--..................................................... •-------•------------------•••------•-•••---------•---•-••------•-------....------•-•-----•-------•---
U Nature Repair or Alteratio —Answer when is ,lF`�' . .1 0 - -_. .......
Agreement:
The undersigned agrees to install the a edescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State S itar Cod —The undersi ned f grees not place the system in
operation until a Certificate of Compliance as n .s -by th r
Sign ---•- ........ ••. -•--..... .......`........ .....• l�
Da e
Application Approved BY - A................................ ---- ---- ---------------••-•-••----. //- �F_:__.;.3
Date
Application Disapproved for the following reasons:---•------•--•••----•--------••---•--•-----------•---•••-•--•----••---•--•---•----••-••-••..................
-------•-----------------------------•-------------------.....--•--------......-----------••--------...---••----••----•-•-•------...---------------------------------•------•----------•---•---•--•••---
`O �� Date
Permit No. /......--- Issued
Date
_._..._...._.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
... -----...._.OF.........?C�3r` : f. ........... L,E
r , ppltration for Dispusa1 ork Tomitrurfi au 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System t
.._ �'.j... �= •,�T- ,, `../i fi ............ ........::.-= -...--!�....... ,z� _ �. �?.. ..........
�^ Location-Address t� Lot No
......................-j [s/f.. t�j:.G!......................... ...7�J �/, /�� / ! �... ....................
---
_ Owner Addressrs:
-r .: Su�uac, _/',�� ;%3-------...............
.�'-�� li==- % 1�......
Installer Address
QType of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic '( ) Garbage Grinder ( )
pal Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures -----_---•--•-_-----•------•••.._...._....
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water.....................
Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a'
' D Description of Soil......s� / ' ------------------------------------•-------------------------------------- ------- --- -------.--------•------...---------
x
W _
x Nature of Repairs or Alterations.—Answer when applicable--------.`Z ! 5 ..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Saxtitarl Cod The undersigned furtliexiagrees not/to place the system in
operation until a Certificate of Compliance has bean ssu b theeboard.of'h�t=K.
P P '` �� ....,�................................... �-�
Application Approved By.............. ft I //ate.,
W.5
------------------ -----
Date
Application Disapproved for the following reasons...............................................
----------------------------------••--•-•-.. ......---------
................•---........----•----......... ..................................... --•...•--•-------•-••••----•---•••-----•---•------•---••-----•---•---••-............••........_
Date
PermitNo... .........................•--•-•--------•-------_. Issued_---==:_:..............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH i.
(Irrfifiratr of Tuutpliatta
HIS-IS TO CE.TIFY, That the Individual Sewage Disposal System constructed
( )t or. Repaired (�)
by.... _ ...C�i` 5/ vGC ( "l'!%` .•�--/----�` ... -- /. i4.-G`-•..----'.....i....... •----/f./�7sc/i'//5-------------
Installer
. � r� .S `i4f�✓'�'trt, y f1__/>._......
has been installed in accordance with the provisions of T�z j of The State Sanitary Code as de4c ibo in the
f ,/e'f /✓ .. rr •.. y
application for Disposal Works Construction Perm>t No_____________ _______________________ dated-._.`_.._...-.__......_-..._-_........._._.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS E® AS A GUARANTEE THAT THE
SYSTEA W L UNCTION SATISFACTORY.
DATE. --�..&......................................................... Inspecto --• ...............................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J�t'�=✓r;f ........OF........ J•'°.r......�.....%f��L•-,�. .................... �� �
No... ------------- FEE...-...."..._..........
Disposal Works TIMunufrttrftun unfit
Permission is hereby granted-. f�... �" 'L IS%`iv-lei- -IGE...............................................................
to Construct ( ) or Repair (> an Individual Sewage Disposal S stem
at No.. S !"'i? S7'• %fif/�//+//-S ,J,--, . `3f-1 �� , 457 ����r_ e--
........................--•---------•----•---------. ----------------•-----•-•----•--------•----------------------••-•-----.....•---•-
Street
as shown on the application for Disposal Works Construction Permit No.__�1_7 ____ Dated--___r/ '?........:...
.......................................... l -------•--............
and of Health
DATE ------....C . ..
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS /� -
i
LOCATION �; SEWAGE PERMIT NO'.
VILLAGE
A & B -CESSPOOL SERVICE
128 BISHOPS TERRACE, HYANNIS, MA 02601
BUILDER OR OWNER i
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DATE PER& ISSUED
/r Xtj,�f�3
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DATE COMPLIANCE ISSUED "I
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